VERSIONS AND FLEXIONS OF THE UTERUS.

Version, in the nomenclature of diseases of the womb, means that the entire organ without any deflection in its normal axis turns, inclines or leans either forwards, backwards or sidewards.

The prefix ante is used in the sense of forwards and in composition with version we have the word anteversion, which in conjunction with the term uterus, signifies that the organ is inclined forwards. The prefix retro, signifies backwards, and in composition with the word version and in connection with the word uterus, it implies that the womb is turned backwards.

The word flexion differs from version, inasmuch as it signifies a bending or bowing, which breaks the normal axis of the womb. The neck or cervix of the uterus may retain its normal position, while its body is abnormally deflected or bent in any direction. The prefixes ante and retro are also used in composition with the word flexion as they are with version. These distinctions should be remembered.

ANTEVERSION OF THE UTERUS.

In anteversion the uterus has so far changed its normal shape that the cervix of the organ is stretched out or extended in a line with the axis of the body. This occurs when the uterus is unusually swollen from inflammatory enlargement. The normal location of the body does not materially change in these cases. It is a little more depressed on the fundus of the bladder and the cervix is correspondingly elevated, so that the latter stands considerably higher than in health. If the bladder is empty, and the patient bears down or does anything that increases the intra-abdominal pressure, the body of the womb is forced down, upon the anterior vaginal wall, which prolapses into the vagina, while the cervix is raised, so as to point upwards and backwards. When the bladder is full, the body of the uterus is naturally raised, and the cervix correspondingly depressed. And this is attributable to a rigidity or stiffness about the organ, that is characteristic of a chronic inflammatory enlargement of the uterus. Sometimes the organ is permanently fixed by inflammatory adhesions, that lessen or prohibit these movements.

The symptoms of anteversion are what may be expected from an enlarged congested organ. This enlargement is due either to a subinvolution of the uterus or to an inflammation of the intermuscular substance, a chronic metritis. One of the most annoying symptoms of the anteverted uterus is the feeling of looseness in the pelvic cavity. This is partly due to the relaxed state of the surrounding tissue, and partly to the abnormal size of the womb. The patient feels the organ roll from side to side, as she changes her position. This causes unnatural sensations and mental suffering that disturbs the nervous system and induces hysterical complications. And the patient complains about something moving in her abdomen.

The inflammatory adhesions that sometimes tie down the organ in an anteverted position, compromise the normal expansion of the bladder; this induces an irritation, which causes a frequent desire to urinate.

The treatment must be directed to the removal of the cause. This disease is really only a symptom or condition of chronic corporeal metritis or subinvolution, and as such, it is only amenable to the measures that will cure this disease. The employment of rings and pessaries to remedy this evil is contrary to good sense and of no permanent value.

The intelligent employment of electricity, so as to stimulate the absorption of the hypertrophic enlargement of the uterus and cause the absorption of the inflammatory adhesions, will often give permanent and positive results.

ANTEFLEXION OF THE UTERUS.

This was considered at one time the most frequent of all uterine displacements, not because it existed formerly oftener than at present, but because the natural or normal position of the womb was confounded with that which was supposed to be abnormal.

The discovery that in the living subject the body of the uterus naturally inclines forward, so as to rest on the bladder, and that the body makes quite an angle with its cervix, altered the conception of things very materially. To-day an actual aggravated anteflexion, that occasions no impediment to the menstrual discharge, is not a proper ground for treatment, although this is as yet by no means familiar to physicians in general, for many of them have not learned to make the distinction.

The reader should carefully study Plate II, which diagramatically illustrates how the body bows over the bladder so as to show its natural anteflexion. If the angle between the body and neck of the womb becomes too sharp or acute, so that the canal of the uterus becomes compressed at the point of flexion, in a degree that obstructs the escape of the natural secretions of the uterine cavity, then the anteflexion becomes a source of disease. This degree of flexion is happily very rare, and we find it in about equal proportions due to a congenital defect, that springs into prominence when the girl arrives at puberty, for then the obstruction to the menstrual flow is first realized.

The other class acquire the affection in adult life, after a once healthy or natural menstruation has been established. Of this class there are two species, which must be separately analyzed, so as to avoid a confusion of ideas, that often makes this subject, which is the most simple, one of the most intricate, in the text books in gynecological practice.

One variety of the acquired affection can be described, in common with the congenital form, to which I first referred: because the anteflexions in both cases are due to precisely the same pathological conditions, namely, a loss of muscular tone in the uterine walls, so that the organ becomes flabby and weak, like a green wilted stalk, allowing the body of the uterus to topple forwards.

The relaxation of the uterine walls is usually more pronounced at that portion which is distinguished as the isthmus of the uterus, and corresponds to that part of the organ where the cervix goes over into the body, forming a sort of natural hinge joint between body and neck.

If the bladder is empty, the body of the womb will naturally drop, not necessarily forwards, for it may fall backwards, but in the majority of cases it drops forwards, because the womb is already inclined forwards in its natural position, so all that is necessary to induce an excessive anteflexion, is for the body of the uterus to sink lower than it is natural for it to be. A kink or sharp bend will cause in any canal an occlusion. Take a small rubber tube, for instance, and bend it sharply at right angles; the result will be at the corner of the deflection, that the tube will be flattened, and its walls will come together. In the case of the uterine canal, where there is an abnormal flexion, there is precisely the same condition, and as a result an obstruction not only to the menstrual fluid, but to the mucous secretions, which are pent up in the uterine cavity. The retained fluids decompose and irritate the mucous lining; and this entails a complication of inflammatory diseases, which can never be cured, unless the flexion is remedied.

The other variety of the acquired flexion is due to a pelvic cellulitis. This is an inflammatory process, entirely outside of the uterus.

The womb is surrounded by a great deal of loose cellular tissue, that fills out the interspaces between the different ligaments and pelvic organs. This tissue often becomes the seat of an inflammation. The exudation from the inflammation may be of such a nature that it forms strands of fibrous tissue, running from the isthmus of the uterus backwards to the sacrum. These strands contract or shrink in the course of time, and this draws the isthmus of the uterus backwards, and fixes or attaches it to the posterior pelvic wall. By this contraction of the fibrous tissue the cervix is constricted and the body falls unnaturally forwards.

The prominent symptoms of anteflexion are painful menstruation and sterility. Dysmenorrhoea or painful menstruation is the first sign of the existence of anteflexion at the age of puberty. It happens that young girls are thus tortured for days with violent uterine colic, that is occasioned by spasmodic efforts of the uterus to force through the constricted canal the pent-up secretion. This lasts until the menstrual fluid has sufficiently dilated the cervical constriction to allow its escape. These painful paroxysms of uterine colic repeat themselves at each recurring menstrual period, and through these repetitions of pain and suffering, the general health becomes greatly deranged. The nervous system becomes the seat of functional disturbances, and hysterical disorders are not uncommon.

The organ becomes involved in chronic inflammatory processes that make the uterus exceedingly sensitive, so that the colicky pains become aggravated and prolonged far beyond the cessation of the menses. Some of these patients suffer for several weeks, from the time the courses ought to begin, so that they are actually sick half the time.

Sterility is not an absolute certainty in all these cases, but it is traced so often to an aggravated flexion, that it may be accepted as one of its most prominent signs. Conception has taken place in extreme flexions, because the spermatozoa can gain admittance into the uterine cavity for several days after the uterine colic and menstrual fluid have forced the canal open. And if the uterus has not become involved in inflammatory processes, then conception is the means by which nature effects a cure through her own resources.

During the menstrual period, the anteflected uterus becomes greatly congested and swollen, and, having already grown considerably larger from the chronic inflammatory conditions which the anteflexion has induced, it impinges on the bladder, so as to interfere with its free expansion. This occasions a frequent desire to void urine, and this becomes a very distressing symptom in a certain proportion of cases.

Treatment for this affection is not within the sphere of the original purpose of this work, for the efforts at home treatment must be aided by mechanical methods of the physician. From what we are taught of the physical cause of this affection, the fact seems self-evident that the acute or sharp flexion must be modified to give permanent relief. The employment of rings, pessaries, sponges or medical applications are nonsensical, and the method of introducing a stem in the uterine cavity, for the patient to wear for an indefinite length of time, is not without great danger. Even though a woman cannot give herself all the proper treatment, it must be a great satisfaction to her to be informed of the proper methods that should be adopted.

The vagina should be thoroughly rinsed before each and every treatment of the uterus, so as to guard against the possibility of infecting the cavity of the uterus.

If the manipulations that are required for the purpose of carrying out some of the mechanical or surgical treatments of uterine diseases, were always preceded with thorough cleanliness, which implies asepsis, or without putrescence, then all these operations would be shorn of their greatest danger, namely, that of exciting inflammation and suppuration.

If a probe of the usual curve can be readily introduced into the supposed anteflected uterine cavity, then there cannot be sufficient flexion to constitute an obstruction, hence the flexion is not the cause of the disease. In genuine anteflexion, the cervix and body of the uterus are doubled up on each other, often like the letter V, the cervix representing one line of the V, and the body the other; bi-mammal palpation in the hands of an expert clearly establishes this conformation.

When the diagnosis is established, the treatment should be as follows: The patient is inclined on a table, either on her back or side, a Sims’ speculum is introduced into the vagina and the cervix exposed. The posterior lip of the cervix is now seized by means of a tenaculum forceps, and gently drawn downwards and backwards, which greatly reduces or obliterates the angle or flexion between the cervix and the body of the womb, this greatly facilitates the introduction of a uterine electrode. After two or three treatments, the forceps are no longer required because the electrode can then be readily introduced into the uterine cavity without them. The other electrode is spread on the abdomen. (See this illustrated on Plate V.) A current of electricity is now passed through the uterine tissues for ten minutes; this is gauged all the way from sixty to one hundred milliampÈres. The operation is repeated only once a week, and the cure is effected in six weeks to three months. Great care must be exercised during the treatment, to avoid exposure and undue exercise.

Those forms that are due to inflammatory deposits and strands outside of the organ, should be preceded with an electrical treatment twice a week, somewhat modified from the preceding course. This is done by employing a vaginal electrode, properly protected and gently pressed against the adhesions. The other electrode is applied to the small of the back. A current some fifty milliampÈres stronger is passed directly through the adhesions; when these are absorbed, the intra-uterine electrode is employed, as in cases that are not complicated with them.

RETROVERSION OF THE UTERUS.

This consists in a posterior inclination of the uterus, so that the body of the womb approaches the posterior walls of the pelvis, while the cervix of the womb is raised against the base of the bladder.

As a permanent pathological lesion, this form of displacement is very rare, but as a forerunner of retroflexion it is of frequent occurrence. The length of time that elapses for a version to take on a flexion depends on the degree of induration or stiffness of the uterine walls.

The chronic inflammatory enlargement of the uterus predisposes the organ to posterior displacement, and the displacement favors the development of flexion. This takes place in the following order: After the uterus is displaced backwards, and its cervix has become fixed by inflammatory adhesions, the body of the womb gradually glides down on the posterior pelvic wall, from gravitation and intra-abdominal pressure. And in this very simple manner a retroversion is converted into a retroflexion. The causes, symptoms, and complications that characterize this variety of displacement, with its subsequent modification into flexion, are the same as those of retroflexion, to which the reader is referred.

RETROFLEXION OF THE UTERUS.

This form of uterine displacement exists when the body of the womb is bent towards the posterior wall of the pelvis, which is in an opposite direction to that where it naturally belongs. I have already pointed out, in speaking of the normal position of the uterus, that the body is directed forwards and rests on the bladder, while its cervix points downwards into the pelvic cavity. I now refer you to Plate IV, in which I plainly show the uterus in a directly opposite position to that in health, namely, turned back, resting on and depressing the rectum.

In retroflexion the cervix of the uterus continues to point downwards, into the pelvic cavity, in almost the same direction as in the natural position, while the body is directed backwards, or backwards and downwards. We seldom, if ever, find this condition as a congenital affection, but as an acquired displacement it is undoubtedly more frequently met with in gynecological practice than all other displacements combined. The round ligaments of the uterus were at one time, and are even yet by some, supposed to be the means that retain the womb in its normal anteflected position. Upon this theory a new surgical operation sprung into prominence for the relief of this class of cases. It was reasoned, that if the round ligaments actually tied the uterus down, and retained it in its natural anteflected position, that to shorten these ligaments by opening the inguinal canal in the groin, and drawing them out, would remedy a displacement of the womb, whether a prolapsus or a retroflexion. This operation was performed, it was claimed successfully, and if the view that the round ligaments retain and support the uterus were a correct one, it must be admitted that the operation would have been ideal. I convinced myself, however, of the utter fallacy of this position, in dissections on the cadaver, where in several instances the round ligaments could not be reached without opening the abdominal cavity, and even then it was impossible to trace them. These views were expressed in an article in the American Journal of Obstetrics and Diseases of Women and Children, and as the operation fell shortly afterwards into merited disrepute, I partly claim the credit of having been instrumental in bringing that about. I said:

“That this ligament has nothing to do in fixing the uterus in its normal anteverted position, is proven from many facts which occur in daily practice. The insertion or origin, whichever one chooses to call it, of these cords at the groin, is somewhat irregular and sometimes so rudimentary that it cannot be found upon a most careful and tedious dissection. It may be found divided into a number of processes, one being connected with Poupart’s ligament in the inguinal canal, the other being lost in the labia majora, and another may be traced to the sheath of the rectus muscle.

“If these cords were so important as the advocates of the Alexander-Adams operation try to make us believe, in binding the uterus forward, and, as we are recently informed, have a strength equal to support four and one-half pounds weight, a great deal of uneasiness, if not actual pain, would be felt and located along the inguinal canal, following this structure to its points of insertion, in sudden dislocations of the uterus backwards. This is, however, not the case; when sudden painful symptoms arise, they are invariably referred to the sacral region. In sudden retroversions or flexions, as in the pregnant uterus, occurring accidentally or those retroverted or flexed uteri which are so often met with in a state of subinvolution after confinements, there are no symptoms pointing to a tension of these cords at all, but all symptoms point to uterine pressure on the posterior pelvic wall, which can be precisely located. And these pains disappear as soon as the offending member is put right.”

There is no doubt that the uterus retains its abnormal retroflected position by the same forces that keep it in a normal or anteflected state; these are (1) intra-abdominal pressure, and (2) the force of gravitation of its own weight.

In some women there are certain predispositions to the occurrence of a retroflexion. If the walls of the uterus are weak and relaxed, especially that portion where the cervix unites with the body of the womb, then the body may fall in any direction, and, as the bladder is liable to be distended, and thus raise the body of the uterus upwards, folds of intestine are likely to intervene, so that the organ is inclined backwards, and the abdominal pressure, now falling on the anterior surface of the body, presses the womb backwards and downwards into a flexion.

A fall backwards or a violent push or jump may cause retroflexion any time during life. Retroflexions of this nature are not as a rule injurious, and if the circulation is not compromised, nor the uterine canal obstructed, women may go through life without feeling any the worse because their womb occupies an abnormal position. It is only when the organ is congested and swollen, so that its own tissue is painfully sensitive, and the surrounding tissues are compressed by the foreign body, that it requires measures for relief.

In those women who have borne children, and those who have gone through a miscarriage, retroflexion is frequently met. A little reflection will make this clear, for when we remember how the pregnant uterus at any time from conception to final delivery becomes congested and the seat of a corresponding growth of its own tissue to accommodate the growing fetus, we at once perceive that either after an abortion or on delivery at full term, the enlarged and congested uterus is in the best possible condition, to lose its normal place and sink backwards. The pernicious custom in vogue in most countries, of keeping a woman on the flat of her back after delivery, has never been as vehemently opposed by the intelligent members of the profession, as the gravity of the subject demands. Some women have an idea that the longer and quieter they remain on their backs, the surer they are to make an excellent recovery from the lying-in chamber. American and English practitioners are inclined to recommend this as the most proper way to lie, but there is no doubt that this not only favors the occurrence of retroflexion, but that it actually causes it.

The woman who rests on her back gives to the heavy body of the womb an opportunity to sink backwards, after the distended bladder has pushed the organ high enough up so that its own weight may throw it over, until it finds resistance on the posterior wall of the pelvic cavity. Many nurses insist on the dorsal position for days, and never permit the patient the privilege of lying upon one or the other side. Aside from the injurious effect that this has on the position of the uterus, it is exceedingly tiresome to be compelled to remain for several days in one position. Women should be allowed to lie on all sides, after delivery, and no longer on one side than on another. And to insure against a retroversion or flexion, she must also lie on the abdomen a certain length of time during each twenty-four hours.

Tight bandaging after delivery, for “preserving the figure,” greatly aggravates the displacement; the binder should be so applied that it feels comfortable but not too tight, its purpose being to offer a gentle support to the suddenly relaxed abdominal muscles, and thus stimulate them to contract to their normal form.

The symptoms of retroflexion are greatly varied by the pathological conditions that affect the uterus, or by the complications that may have caused the flexion.

It is indisputable that the uterus may be retroflected for an indefinite length of time without causing any inconvenience. From this it may be inferred that the retroflection itself does not constitute the disease, but the inflammatory processes, in which the organ is involved, or the relaxation of the adjacent structures, as we find them immediately after confinement, constitute the actual diseased conditions.

One of the most constant symptoms is pain in the back, and this is severe in proportion to the swelling and sensitiveness of the organ, when it presses on the sacral nerves and rectum.

As a result of the flexion, the circulation in the organ is interfered with, so that the congested uterus feels heavy, and there is a sensation of fullness and bearing down, that greatly hinders walking. Uterine catarrh and hyperÆmia place the organ in such an irritable state that prolonged and excessive menstruation is the rule. This may last for fourteen days, so that the patients become anÆmic and greatly debilitated from the excessive loss of blood. The menstruation is always more painful, especially at the beginning of the flow; this pain may be interrupted or spasmodic, so that it assumes the form of a uterine colic; the lower abdominal region becomes painful and the pain radiates towards the groins. The degree of suffering is very seldom as great as that which characterizes anteflexion, because the obstruction in the latter flexions are much greater than in retroflexions.

Those women who have borne children suffer less pain during menstruation than those who have never been pregnant. It may be presumed that, in the latter class, the flexion was congenital or acquired in early childhood, which makes the obstruction or constriction more complete and obstinate, and for that reason it induces sterility. With those who have once borne and afterwards acquired the flexion, the possibility of conception is much greater.

When the enlarged and swollen body of the uterus is pushed backwards and downwards, it presses on the sacral plexus of nerves; this is a bundle of nerves that supplies branches to the legs, and from this pressure the lower extremities become lame or paralyzed either on one or both sides. The paralysis subsides after the removal of the offending body. There is quite a number of other neurotic affections that can often be traced to a retroflected uterus. These are all of a functional nature, and appear in the form of hysteria, epilepsy, St. Vitus’ dance and neuralgias of almost any part of the body. Dr. Chrobak, of Vienna, reported a case of asthma that had resisted all the treatments that could be suggested, until it was finally traced to a retroflected uterus; that being rectified, the asthma subsided.

Irritability of the bladder is not so frequent a symptom of this variety of displacement as of others; should there be inflammation complicating the bladder, then, of course, there would be considerable annoyance from this source.

Habitual constipation is often very prominent and in some of the cases it is the only sign that leads to an examination, which reveals the retroflexion. Hemorrhoids or piles, due to a compression of the veins of the rectum, are another complication included in the signs of this displacement.

TREATMENT.

There is a small proportion of cases in which the system has become accustomed to the retroflected position of the womb, and if the abnormal condition is rectified, a great many painful symptoms spring into prominence, that are attributable to the interference. This is particularly the case in women who are in those years that we term “change of life,” and for this reason they should be let severely alone.

Excluding the above class of cases, the question arises in other cases whether the uterus can be replaced without violence, or whether it is fixed or grown to its surroundings by inflammatory adhesions. It is not always an easy matter to dispose of this question at once, because the enlarged and congested body is often so firmly wedged down between the posterior pelvic wall and the vagina, that any attempt to dislodge it is accompanied with such acute pain that one feels constrained to desist for a time. When there is great pain or sensitiveness, the patient should take to bed, so as to give the pelvic organs every chance to get rid of the inflammatory irritability. Hot-water compresses should be applied to the lower abdominal or pelvic region, and hot vaginal irrigations thrown into the vagina; these should be copious, no less than a gallon of water at once, at a temperature of 107 to 110° Fahr., repeated twice daily. The bowels should be kept loose, say several operations each day, for three or four days; after that once a day will be sufficient.

In the course of several weeks the congestion will have subsided, so that, in the great majority of cases, reposition can be readily accomplished. If the resistance of the womb still persists, then it is reasonable to infer that the organ is tied down by old inflammatory adhesions; these, then, should be treated with galvanism, after the manner described for removing adhesions in anteflexions.

The statistics show that, out of every five women who are suffering from female diseases, one has a posterior displacement, either a retroflexion or retroversion. The greatest number of these are traceable to their last confinement. All these displacements, as well as those that are accidental or induced by a fall, jumps or the like, should be replaced as soon as possible, otherwise inflammatory adhesions may complicate and greatly obstruct the replacement.

The reposition or replacement of the womb may be accomplished through natural agencies, that can be employed by the patient herself. These are, in a great measure, the same forces to which the womb’s posterior displacements are to be attributed, namely, intra-abdominal pressure and gravitation. To employ these for the purpose of remedying the evil, the so-called knee-chest position must be assumed by the patient. The first step towards assuming this position is to get down on the bended knee, the thighs in a vertical position, then the body is gradually inclined forwards until one or the other shoulder touches the floor or level of the knee. If this position is retained for ten minutes it will alone replace the organ forwards, sometimes suddenly, at other times gradually, provided the organ is moveable and not squeezed into the pelvis or adhered by inflammatory exudation.

Dr. Henry F. Campbell, of Georgia, introduced this natural therapeutic agent into the profession, but it appears to be very little known or understood by the profession, perhaps because it is so very simple. Dr. MundÉ, in an article on “Uterine Displacement and Its Curability,” in the American Journal of Obstetrics, indorses the knee-chest or knee-shoulder position in the following language: “A moment’s thought will demonstrate the utility of this combined vis a fronte (gravitation of the abdominal viscera towards the diaphragm) and vis a tergo (air suction into the vagina and pressure against the vaginal roof). This position is to be assumed several times daily, and maintained each time as long as the patient can bear it, continued for months, if necessary; the best time is at night at retiring, when the lateral position is to be taken for the night.”

In a certain proportion of cases the knee-chest position alone will not dislodge the retroflected uterus, so that manual aid is required to effect that purpose. There is a number of methods that have been suggested from time to time, but none are so good as that in which the knee-chest position is combined with the manipulation of the operator. Reposition may occur spontaneously, and it undoubtedly does in a large proportion of cases, in which the retroflected organ becomes pregnant. When the retroflected organ occasions symptoms of retention of urine, the bladder should first be emptied with a soft No. 8 catheter, then the patient is directed to kneel on both of her knees, her thighs remaining perpendicular, while her body inclines forward until one or the other shoulder touches the floor or level of her knees. The operator may then gradually lift the womb and elevate the body sufficiently so that it will fall forward into its natural place. When there is no bladder trouble from compression, and the womb resists even mild force to replace it, I have accomplished gradual reposition by keeping the woman in bed for three or four weeks, with the instructions that she resume the knee-shoulder position two or three times a day, and from five to ten minutes, also that she shall lie on her side and chest and never on her back. In this manner I have accomplished in time and without force what could not have been accomplished with forcible attempts without inducing an abortion.

It curiously happens that there are cases of retroflection which are never suspected nor recognized until the patient has become pregnant. After the woman is about three months gone, the growth of the pregnant uterus can no longer be accommodated in the pelvis, because the direction of its growth is in the direction of the retroflected organ, namely, backwards and downwards (see Plate IV) which makes it a physical impossibility to escape from or grow out of the bony pelvis. The symptoms are retention of urine or a constant dribbling of urine and a straining at stool or pain in the rectum or pelvis, and, of course, the absence of the menses since the commencement of pregnancy. Retroflection may be also acquired during the first three or four months of normal pregnancy, from a jump or fall on the back, in which all the symptoms that indicate this condition are suddenly manifested.

In pregnancy, the course that is to be pursued, in order to rectify the displacement, must be obviously different from that pursued when the woman is not pregnant. The pregnant uterus is a “touch me not;” it permits of no tampering without running the fearful risk of inducing an abortion, and no one but a tyro or an ignoramus will ever meddle with the pregnant womb.

The replacement of the retroflected uterus, that is positively not pregnant, and there must be no question about it either, will admit of introducing a sound into its cavity. This sound is used as a lever upon which the organ may be lifted out of its abnormal position and inclined over the bladder in an anteflected position, which is its natural one. The sound which I employ, and which is my own invention, for replacing the uterus is screwed into a thimble, and from two and one-half to three inches long. The object of this is to artificially elongate the finger so that it can be introduced into the womb. The force which one employs by using this instrument is keenly appreciated by the operator, hence there can be no undue strain, that otherwise might be exerted on adhesions which are too strong to be safely lacerated or even stretched, while slight and recent adhesions might be torn without any bad results. Truax, of Chicago, manufactures my repositor.

Before introducing any sound into the uterine cavity, it is absolutely necessary that the vagina should be thoroughly cleansed with borax water.

The inflammatory enlargements of the womb, subinvolutions, uterine catarrhs, and any of the complications that may exist at the time that the organ is replaced, should be treated on the same principles that have been laid down in the respective chapters on these diseases; in fact, these complications constitute part of the after treatment for retroversion or flexion. The other treatment is to be directed toward retaining the womb where it naturally belongs. The daily exercise in the knee-chest position should never be neglected, and in cases in which this is insufficient, it is very probable that the pelvic floor or natural support of the uterus has been injured or lacerated during confinement, and this may require a plastic operation as a preliminary to a cure. In obstinate cases there is no cure so effectual as pregnancy and a full-time delivery, provided precautions are taken so that the mother will not acquire a new retroflexion during her lying-in period, from the cause that has been already detailed. The patient must accustom herself to sleep either on the chest with face turned to one or the other side, or in a semi-prone position on either the right or left side. Perseverance in sleeping in this manner for a few weeks cultivates the habit that gives more refreshing sleep than lying on the back, which most persons are inclined to do.